Men's & Women's Health Physiotherapy

Hard Flaccid

What is hard Flaccid Syndrome?

Hard Flaccid Syndrome is a condition affecting the penis and is of unknown aetiology among men. However, hard flaccid synrome is believed to be more prevelant between the ages of 18 and 35. It is characterised by penile stiffness when the penis is in a flaccid state and flaccid size. The penis is essentially stiff to the touch, it is engorged and rubber in texture, and is often accompanied by a change in size or shape of erection. There may be a loss in nocturnal erections and it may require a greater degree of stimulation to achieve an erection. However, the most common reason for someone seeking help when suffering form hard flaccid is because of alarming changes in penile shape and size. Patients often self diagnose hard flaccid from reading online forums. It is different from peyronines disease because there are no visible signs of tissue scarring and plaque formation. Nevertheless, hard flaccid is a distressing and poorly understood condition. At Core Body cliniic, our pelvic physiotherapists are experts in the treatment of Hard Flaccid syndrome.

Until recently any male pelvic pain syndrome would fall under the umbrella term of Chronic non-bacterial prostatitis often leaving men in the no-man’s land of diagnostic labelling and therefore at a loss as to how their pain and symptoms could be rectified.

Hard Flaccid syndrome has largely been the subject of discussion and debate on male pelvic pain forums with little or no clinical information about the condition. Therefore, diagnosis is difficult to the untrained eye and often clinicians are often at a loss about treatment. Seeing a male pelvic physiotherapist who has expertise in male pelvic pain and pelvic dysfunction is the starting point. It is often useful to be assessed by a urologist prior to booking.

What causes it?

With little by way of clinical research concerning hard flaccid, much of the theories relating to the pathophysiology are based on our observations of the patients who present in clinic. However, in combination with the knowledge of anatomy and pain mechanisms an understanding has been developed which has enabled us to provide treatment solutions.

Injury to the penis and stress are likely drivers for this condition. Our own practice at Core Body Clinic has observed many patients who present having engaged in excessive masturbation, exhaustive sex or who have attempted penis enhancement stretching. Such situations see the penile muscles in sustained contractile states leading to venous compression in the penis. The blood vessels therefore failing to empty when in a flaccid state with blood remaining in the erectile tissue. Erectile tissue fatigue occurs, as one would see in many other muscle tissues in the body. An almost spasm like behaviour where the regulatory control of erectile function is lost and the erectile tissue fails to disengage fully. Likewise, in a continued semi stimulated state, the tissue struggles to fully erect because it has lost the normal feedback mechanism. Autonomic and central nervous systems control erectile function and in states of fatigue the central and parasympathetic nervous system can no longer regulate this function. Pain is common due to tissue injury and chemical irritation of nerve endings, caused by fatigue chemicals. This further results in anxiety and distress. We know that psychological drivers transfer into biological processes. Stress causes the release of cortisol, adrenaline and no-adrenaline resulting in increased blood flow to the pelvic area. Exposing already traumatised blood vessels to increased blood flow only helps to drive the process and maintain a hard flaccid state.

Tension in the pelvis is strongly linked to stress and this in turn will help to maintain the poor regulation of blood flow in the pelvic floor. The origin of the penile muscles from within the pelvis allows for easy influence of the tight pelvic muscles on the penile erectile tissue. There is often associated tension over the perineal and anus regions.

What can we do about it?

Understanding the patient’s drivers and educating our patients about their condition helps with anxiety about the condition. Information concerning the onset of symptoms is essential in removing any harmful behaviours or practices and emotional drivers. Often this is a distressing and difficult time for the patient, and in some cases the cause is elusive and requires careful history taking to unpick the possible triggers.

Relaxation plays a significant role in re-establishing normal breathing patterns thereby facilitating appropriate abdominal movement. Interruption of the normal diaphragmatic excursions during breathing is closely associated with pelvic tension. Hard flaccid is distressing and leaves the patient in a state of anxiety causing shallow breathing, abdominal bracing and abdominal muscle fatigue.

Physical therapies such as trigger point release and massage to the perienal area and internally within the pelvic floor helps to provide feedback to patient and clinician about tension in the pelvis. With careful and skilled practice it is possible to remove this tension to alleviate pain and tissue tension.

Exercises to restore normal pelvic floor control is essential. Quite often online forums encourage the ‘Kegal’ exercise and many men attend the practice having done these only to end up in a worse state. We tend to focus on the ‘reverse kegal’. This differs from the kegal by pushing the pelvic floor down rather than lifting it up. It aims to de-tension the pelvic muscles.

Hard flaccid can also occur with weight lifting with patients believing that they have lifted excessively as the cause for the initial onset of symptoms. Therefore, there is a reluctance to get back to training and part of therapy is to coach the patient about normal lifting practices and ensure their breathing pattern and pelvic muscle control is appropriate.

Hard flaccid is a difficult condition to treat. Specific men’s health physiotherapy is highly successful in resolving this condition.

Core Body Clinic is specialist center for the treatment of Hard Flaccid.

Men's Health Physiotherapy

Men’s Health physiotherapy is a specialist branch of physiotherapy that deals with male pelvic pain and pelvic organ dysfunction. At the Reading Men’s Health and Sporting Pelvis clinic based at Core Body Clinic we are trained both in musculoskeletal physiotherapy and Men’s health physiotherapy combining a unique skill set to comprehensively assess and diagnose problems affecting the pelvis.

Incontinence

Our pelvic therapists at Core Body Clinic are experts in treating Incontinence. We understand it and we really care about helping you.

We treat Men and Women.

Incontinence is characterised by an inability to maintain control of your bladder causing leakage or a feeling that you need to do to the toilet even though you have just been.

You will have often seen a doctor or surgeon and you have been advised to seek the help of a physio. If you have not then we recommned you do this in addition to seeing one of our therapists.

Incontinence can develop, after having a baby: as we get older; because of gynaecological surgery; excessive strain during sport; because of pelvic pain; after strenuous and prolonged activity; and, sometimes during sex. It can also be as a result after prostate problems, bladder cancer, prostate cancer or injury to the penis.

Incontinence is classified into 4 types:

1 – Stress Incontinence: You leak when the bladder is under stress because you laugh or cough. Sometimes when you are running.

It is caused because of damage or weakness to the pelvic muscles. They have been stretched during labour or injured in surgery (gyanecological, prostate, bladder). Sometimes activity and strenuous sports that place huge downward forces on the pelvis may develop stress incontinent condition. Rectifying the control is highly achievable and should be done to prevent chronic conditions.

2 – Urge incontinence: You feel a sudden need to void and you leak before making it to the toilet. This may be a change in position from sit to stand.

It is caused by instability of the detrusor muscle or overactivity. This can be the result of surgery, infection, interstitial cystitis. Sometimes it may occur during labour and as such there may be a combination of Urge and Stress incontinence.

Turn it off!

3 – Overflow incontinence: This is also called Chronic Urinary Retention. It describes the bladder where it is still carrying water and has not emptied. Your body continues to fill more urine on top. You leak because the bladder is trying to empty.

The cause is usually a blockage within the bladder of urethra thus preventing the bladder from being able to pass urine out.

4 – Total Incontince: this describes constant leakage as the bladder cannot hold the urine in.

This is congenital abnormality developed from birth; it can be a result of spinal cord injury also. It can also be surgically induced after cancer to remove either the bladder, prostate or after extensive gynecological surgery.

Your physiotherapist will know how to assess this condition and provide treatment. By taking a careful history, the physiotherapist will detail the exact cause and therefore tailor a specific treatment protocol to rectify the problem.

Bladder habits and diaries are essential for us to understand the extent of your weakness or bladder activity. We can then modify your activities and prevent incontinence by using a combination of:

Pelvic floor activation protocols

Bladder behaviour modifications

Lifestyle changes

Diet alterations

Understanding how you live and making subtle changes can profoundly effect the bladder. It may be as simple as reducing alcohol, reducing caffeine and eating at set times.

Pelvic floor routines alter how you sense that there is a need to activate muscles. Training your body to control these muscles gives the patient back to the confidence to live normally while safe in the knowledge that their pelvic muscles will prevent leaking.

Understanding how these muscles work enables the patient to activate the muscles on demand. A common mistake is that the muscles are switched on all the time causing fatigue and weakness. It can also cause pelvic tension which in itself leads to incontinence.

Assessment will enable the physiotherapist to determine the muscle type. Is it s slow or fast twitch muscle response? By careful evaluation our pelvic therapists will determine the exercise protocol specific to the patient to develop a program that is time efficient and simple to implement.

Assessment:

After a careful set of questions, we will physically examine you.

Male Physiotherapists examine and treat our male patients in most cases. Female Therapists will treat our female patients where internal therapy is required. Most of the examination will be external and will include palpation of the abdomen. It may include direct palpation of the perineum or instruction to the patient to palpate their own perineum (saddle region between the rectum and scrotum). We may also palpate on the inside of the pelvis. Gaining access requires palpation through the vagina or the anus for women and if appropriate, via the rectum for men. This is by no means an absolute necessity but remains the gold standard for assessment of the pelvic floor. Total understanding and a complete explanation, and only after consent in a written format are any form of internal examinations conducted. Dynamic ultrasound may also be used to achieve this. Internal examination, while useful, is not tolerated by all patients and is never forced upon a patient.

It may be necessary to use a stimulator like a Kegal 8. This can determine the extent of weakness in addition to providing a start to training.

The treatment plan will be discussed and commenced on the day of your first visit.

Prostatitis and Chronic Pelvic Pain Syndrome (CPPS)

Chronic Prostatitis or Chronic Pelvic Pain Syndome (CPPS) are often considered Synonymous where pain in the pelvis is of a persistent nature. In Prostatitis, there is often as an infection affecting the prostate gland. However, only about 5-10% are actually bacteria related with the vast majority related to inflammation or non-specific pain syndromes. Prostatitis can affect all men at any age and accounts for about ¼ of all pelvic pain conditions, genital or urinary conditions in young to middle aged men. Where pain persists after a period of time and after medicine has failed to resolve pain, CPPS or Chronic Prostatitis is a diagnosis assigned.

Diastasis Recti

Diastasis Recti - means separation of the abdominal muscles. The abdominal muscles consist of the rectus abdominus, the deeper transversus abdominus, and then the internal and external oblique muscles.

Separation of the linea alba during pregnancy is inevitable. The muscles need to separate to ensure the bady has room to grow. As the pregnancy comes to a conclusion, the muscles will remain separated for a few weeks and with natural progression they will come back together and a solid and continuous membrane will reform connecting the rectus muscles.

It can also occur in men! Chronic changes in breathing patterns, weight gain and age can cause a seperation.

For some women, the muscles never fully reconnect and they are left with a continuous separation. More than anything it can be an area which causes a great degree of distress and on occasions discomfort.

Addressing the separation is always on the mind of women post-partum. It is essential that they get their abdominal and pelvic floor muscles back to full function to ensure they have the necessary muscle strength and for the prevention of urge and stress incontinence. It is also important so that they can have a healthy sex life and feel confident in their bodies. Weak muscles have far reaching ramifications with the loss of sports participation and the comorbid factors that can develop from abstaining from physical activities due to the lack of confidence in the abdominal and pelvic floor muscles.

Seeing a pelvic floor therapist is essential and can guide you through the necessary exercises.

DONT START EXERCISING UNLESS UNDER INSTRUCTION!!

Doing the normal exercises or sit up routines can result in a worsening of the gap. Over exertion can result in the muscles contracting and pulling the opening wider or certainly not closing the gap.

It is first necessary to understand how large your gap is and for this it is best to see a physiotherapist with expertise in

this type of problem. Next you will need to have exercises prescribed that meet your level of separation. It is pointless to give you exercises that are too easy or difficult. Furthermore, you will need to learn the necessary techniques to ensure the muscle contractions are 'closing' the gap and not 'opening' it.

Exercising is the right thing to do but you need to find the right ones for YOU!!

What to expect:

We will take a comprehensive history and examination of your problem to determine whether there were any problems during pregnancy.

We will establish what you have done up until now and whether you have tried to rectify the problem yourself. This will include understanding the type of exercises you have already undertaken.

Next, we will ask about your expected activity levels so that we can ensure you have a plan of action going forwards that will guarantee a smooth return to pre-pregnancy activity.

Examination will consist of postural analysis, testing the strength of the core muscles and measuring your gapping.

We will ask you to perform a sit up to see the effect on the abdominal separation.

Treatment will begin immediately as we will often start the assessment of the separation by asking you to contract the pelvic floor muscles and the deeper transversus muscles. This often has a positive effect on the abdominals and it is important to see if you can contract these.

The treatment plan will be established in the first session and we will provide you with simple exercises to ensure you can remember the format of the technique and the correct delivery of it. Poor adherence to exercise is often because the physio or exercise professional has not helped you to understand the activity. Our goal is to make you an expert in your own condition so that you can master the exercises and feel confident in what you are doing.

Both Abarna, Rachel and Adrian are pelvic health practitioners. Rectus problems do not require the removal of any items of clothing other than exposure of the abdomen. The physical contact of the therapist on the abdomen will be to determine the extent of the separation. Please see Abarna or Rachel if you prefer to see our Female practitioners.

Book in to see one of our pelvic health therapists either ONLINE or by calling 01189310053.

Alternatively you can email This email address is being protected from spambots. You need JavaScript enabled to view it..

Erectile Dysfunction and Physiotherapy

Erectile dysfunction is a deeply personal and distressing problem that describes a condition where an erection is either not possible or is not sufficient for the desired task of sexual activity. It is a condition that can have multiple causes and therefore you must discuss it with the GP. They will look for all medical reasons for this problem and advise you accordingly, conducting tests where necessary. We know that smoking, alcohol, a poor diet and lack of exercise can have an impact (for some) on erectile function. Physiotherapy can be very helpful where the pelvic floor is implicated. We can also advise on exercise, diet and general wellbeing.

Women's Health Physiotherapy

What is Women’s Health physiotherapy and how can it help me?

Women's Health Physiotherapy is a specilaist branch of physiotherapy where the physiotherapist has undergone specialist training and competencies in pelvic anatomy, pathology, diagnosis and treatment. They are trained to assess and treat women suffering from pelvic floor weakness, problems with bowel and bladder, pain in the pelvis and women who have had a baby or who are pregnant and having problems. At Core Body Clinic our physiotherapists are dual trained in musculoskeletal physiotherapy and Women's Health Physiotherapy. They have a detailed understanding of pelvic anatomy and pelvic floor function and they are skilled in many techniques to treat pain and rehabilitate function.

Seeing a Womens Health Physiotherapist can be a life changing moment and help with a number of problems. One in three women are affected from pelvic pain or pelvic girdle dysfunction. It can take an average of 3 years for a woman to consult with their GP or to see a women's health physiotherapist. The wider ramifications are the development of co-health problems through reduced exercise, depression and relationship breakdown. Women's health physiotherapy is essential after giving birth and can prevent future problems with pelvic floor weakness and continence. At Core Body Clinic, our women's health physiotherapists are experts in the treatment of pelvic pain and dysfunction.

Can I see a physio if I’m pregnant?

YES!!!!! The question should be "when should I see a physio?". Pregnancy is hard on the body so some gentle attention can be really helpful for the spine, mother and baby.

Techniques are very gentle and can help alleviate pain, enhance muscle control, improve posture and function.

It is also recommended for pregnant mothers to have a session with our physiotherapist because it can help reduce problems post-natal (after giving birth). We strongly recommend having a check after your give birth to ensure your pelvic muscles are firing.

The educational and one-to-one sessions are brilliant to help you understand the journey the pregnant mother makes and how to best manage your body.

Many conditions can be split into two categories: Pain and/or Weakness.

We can also help with pain and discomfort during and after pregnancy. When you are pregnant Physiotherapy can really help, keep you moving, keep you reassured that you are doing the right things and can help with any problems or pains you may have/develop.

We regularly treat pelvic girdle pain both before and after pregnancy (SPD or symphysis pubis dysfunction now called pelvic girdle pain). Pelvic girdle pain can also occur without pregnancy and can be treated with physioherapy. Careful adjustments can be made to the pelvis and specific exercises to maintain pelvic floor strength can be taught to our patients.

Seeing a physio can help you reduce the gap in the tummy after having a baby (rectus diastasis) by reducing a weak core and strengthening abdominal muscles.

Prolapses are a troubling conditon often requiring surgery. However, our service allows us to assess and in a lot of cases successfully treat the problem with physiotherapy.

Nerve pain like Pudendal Neuralgia can occur in the pelvis and requires delicate assessment. It can affect both men and women.

What to expect on assessment?

The assessment of pelvic pain uses a comprehensive subjective examination where we will encourage dialogue from the patient to discuss their problem in as much detail as possible. We will use differential questioning to hone in on the possible causes of your problem. The history of any condition as told by the patient reveals much more (in many cases) than any test or examination. Therefore, this phase may take a little time to ensure we get all the important information down on paper. Some questions may be of a sensitive nature considering the nature of the pelvic problem. We will always explain why we need to ask such questions and will use our knowledge of pelvic anatomy and skeletal models/diagrams to help with our explanation.

We may also use a questionnaire which helps to diagnose your problem and also to identify an objective marker so that we can accurately identify progress.

Examination may include the lumbar spine, pelvis, hips and pelvic muscles. If you are pregnant the physiotherapist will know exactly how to handle the patient so not to cause worry to the mother and certainly not to bring any harm to the baby. Women’s health and pregnancy physiotherapists are experts in the handling of pregnant women.

Most of the examination will be external and will include palpation of the abdomen. It may include direct palpation of the perineum or instruction to the patient to palpate their own perineum (saddle region between the anus and scrotum). We may also palpate on the inside of the pelvis. Gaining access requires palpation through the vagina or the anus. This is by no means an absolute necessity but remains the gold standard for assessment of the pelvic floor. Total understanding and a complete explanation, and only after consent in a written format are any form of internal examinations conducted. Dynamic ultrasound may also be used to achieve this. Internal examination, while useful, is not tolerated by all patients and is never forced upon a patient.

Once we have completed both phases of the examination we will then formulate an action plan with the patient and begin treatment.

The examination will last at least an hour. In some cases 1hr 30 minutes is necessary.

Treatment:

Muscles can be rehabilitated and retrained and at the Reading Pelvic Health Clinic we are specifically trained to identify pelvic floor dysfunction and apply a bespoke regime of motor control exercises to remedy such dysfunction. Specialised manual therapy techniques for the pelvic floor can be incorporated to reduce muscle sensitivity and facilitate appropriate muscle activation.

· Trigger point therapy: Getting the muscles working properly and rid of the overactive parts in both the low back muscles, hip muscles and pelvic floor muscles. You will also be taught how to do this yourself.

Back pain and Pelvic pain:

Sometimes, people can present with back pain. They may have consulted a regular physiotherapist, osteopath or chiropractor with no success. We have seen people who have even gone down the route of spinal injections only to see a specialist women's health physio and find out that the pain is actually related to a problem inside the pelvis!

Careful and expert assessment is essential and a comprehensive knowledge of anatomy makes for a more complete physical assessment.

Women's health physiotherapy is a good choice if you have back pain and you also suffer from issues of weakness in the pelvic floor, pain during menstruation, pain during toileting or during sexual intercourse. These can be sometimes very sensitive issues. Therefore, having Arbana in our team at Core Body Clinic helps us to reach out to these patients who are in pain but do not know where to turn.

Prostate Cancer: Physiotherapy and Rehabilitation

Prostate Cancer touches one in eight men and many opt for surgery to the remove the prostate (radical prostatectomy). Other treatments include hormone therapy, radiotherapy and in some instances chemotherapy. It largely depends on the stage and grade of cancer. It is accepted that if we live long enough all men will develop prostate cancer cells (you might have to live to 180!). However, they are slow growing and often people die of other causes before the cancer is diagnosed. Radical surgery has a 15 year survival rate of almost 90%. The effects of having surgery can leave a man suffereing incontinence and erectile dysfunction.

Sporting Pelvis and Groin Pain

Troubling groin or hip pain, unresolved by medical and surgical intervention, can be helped by evaluating the function of the pelvic girdle. Our Sports Pelvis service is specifically designed to consider the sporting population with the pelvic girdle in mind. With a background in elite football, we are all too familiar with niggling groin strains, unnecessary surgical procedures and post-surgical complications or pain that can ruin an athlete’s career.

Pudendal Nerve pain / Neuralgia

Pudendal Neuralgia

The pudendal nerve is a major nerve (like the sciatic nerve) arising from the sacral plexus. It is an important nerve for differential diagnosis in cases of CPP (Chronic pelvic pain). The difference between pain arising from somatic structures (muscle, bladder, bowel etc) are that they are often achey or deep. Nerve pain is different and will behave in a manner where manifestations of lancinating, sharp, throbbing or stabbing sensations are experienced. This is what we call neuropathic pain. Pain is often felt along the pathway of the nerve.